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Fewer opioids as effective for pain control after gallbladder surgery
Michigan Medicine investigators found that patients who underwent gallbladder removal surgery received a prescription for significantly more opioids than they ended up using.
Because diversion of leftover opioids is a major contributor to the opioid epidemic, Michigan Medicine implemented a new prescribing guideline, and found they could cut unnecessary opioid prescriptions without negatively impacting post-surgical pain control, according to a research letter published in JAMA Surgery.
“For a long time, there has been no rhyme or reason to surgical opioid prescribing, compared with all the other efforts that have been made to improve surgical care,” Ryan Howard, MD, a resident in the University of Michigan department of surgery, said in a press release. “We’ve been overprescribing because no one had ever really asked what’s the right amount. We knew we could do better.”
Howard and colleagues reported that 170 patients who underwent laparoscopic cholecystectomy at their center between January 2015 and June 2016 received a median opioid prescription of 250 mg oral morphine equivalents (OME), or about 50 pills. A survey of 100 of these patients revealed they only used a median of 30 mg OME, or about six pills.
These data informed the new guideline, implemented in November 2016, which recommended prescribing 15 opioid pills after laparoscopic cholecystectomy (hydrocodone/acetaminophen [OME, 75 mg] or oxycodone (OME, 112.5 mg), plus acetaminophen or ibuprofen as needed.
Within 5 months, 200 more patients underwent laparoscopic cholecystectomy, and their median opioid prescription dropped by 63% (P < .001) without increasing requests for refills.
Howard and colleagues estimated that this prevented the unnecessary prescription of about 7,000 opioid tablets during this 5-month period, and in the press release, Howard estimated the guideline “has kept more than 13,000 excess opioid pills out of circulation in the year since the rollout began.”
Further, acetaminophen and ibuprofen prescriptions more than doubled in the 5 months after implementation, (21% vs. 49%; P < .001), although survey results showed actual use of these medications did not significantly increase from the preintervention period.
Notably, postoperative opioid use significantly dropped from a median of 30 mg to 20 mg after implementation of the guideline (P = .04), with no changes in patient pain scores.
“Even though the guidelines were a radical departure from their current practice, attending surgeons and residents really embraced them,” Jay Lee, MD, also a resident in the University of Michigan department of surgery, said in the press release. “It was very rewarding to see how effective these guidelines were in reducing excess opioid prescribing.”
Howard and colleagues noted that while the results should be interpreted within the context of laparoscopic cholecystectomy, “the framework of this study could be applied to a variety of surgical procedures.” They added that the study “will be used as a template for statewide practice transformation, which may serve as a platform for other states.”
“Pain is an integral part of surgery — we cause pain in the short term so in the long term we can help heal [patients],” Howard said in the press release. “Nearly half of the prescriptions surgeons write are for pain medications, but traditionally we haven’t gotten any training or guidance in it. We hope that this framework we’ve developed can be applied to many more operations.” – by Adam Leitenberger
Disclosures: Howard and Lee report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.